Michael Laff Washington, D.C. – Many patients with chronic illnesses are limited to such a degree they cannot even leave their homes to receive health care. Without proper medical attention, such patients often require repeated and expensive care.

Peter Boling, M.D., a professor of internal medicine at Virginia Commonwealth University, and Katherine Hayes, director of health policy at the Bipartisan Policy Center, discuss the CMS Independence at Home demonstration project during a forum hosted by the Alliance for Health Reform.

A CMS demonstration project called Independence at Home (IAH)(innovation.cms.gov) is beginning to address this situation with a focus on primary care in the home supplemented by mental health and social services. The project, which began in 2012 and was authorized for three years, recorded more than $10 million in savings during 2015,(www.cms.gov) or about $1,000 per beneficiary. At that time, it received a two-year extension to continue until September 2017.

Fifteen practices are caring for more than 10,000 beneficiaries through IAH. These beneficiaries are among the group health policy analysts call the “five and 50” — the 5 percent of patients who constitute 50 percent of total health care costs. Wergin noted that expanding the project would increase access for more patients with chronic illnesses.

“With nationwide expansion of the demonstration, many more practices will participate, and accordingly, many more Medicare beneficiaries with complex chronic illness will benefit from 24/7 in-home visits that are proven to reduce hospital and emergency department admissions and improve overall quality of care,” Wergin stated.

Seven practices received a total of $5.7 million in incentive payments from CMS under IAH in the program’s second year. Two practices in which family physicians are actively represented, Housecall Providers and Doctors Making Housecalls, each received more than $1 million.

Panelists at a recent policy forum hosted by the Alliance for Health Reform discussed how home care helps patients with multiple chronic conditions.

One physician involved in the IAH project described how his understanding of patients with chronic care needs began with house calls and subsequently developed into a more coordinated approach. Peter Boling, M.D., who started making home visits in 1984, said he saw a difference between the care patients needed and the care they received. Interaction between physicians and home health agencies was limited, resulting in a heavy dependence on ambulance calls and ER services.

Now Boling, a professor of internal medicine at Virginia Commonwealth University, is part of the Mid-Atlantic IAH Consortium. He said that during the initial comprehensive visit at a patient’s home, the physician and patient need to have a frank conversation about medication.

“The only time medication reconciliation is done is at the kitchen table,” Boling said.

After that first home visit, patients are seen at least once a month and they receive same-day visits for urgent problems. Boling said there is now partial funding for the social support these patients need in the home, such as calling in construction workers to install bars on shower doors or along bathroom walls for patient safety.

Because many patients who could benefit from home care do not regularly visit a physician or hospital, some might ask how they are identified.

“Lots of people in the community know who they are,” Boling said. “The home health agencies know who they are. The nursing homes know who they are, and the ER doctors know who they are.”

ER physicians, in particular, are aware of such patients because they often make repeated visits for ailments that were thought to have been addressed previously.

Caring for home-based patients with chronic conditions spotlights a need for more medical professionals who have experience working in integrated teams — teams that, Wergin noted in his letter, should always be led by physicians.

“While the AAFP strongly supports team-based primary care and robust cooperation between physicians and all members of the health-care team, the AAFP remains committed to the position that such teams be led by physicians,” he wrote.